=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609301795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOS ABUELOS ARIZONA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2017
-----------------------------------------------------
Last Update Date | 05/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 W DANFORTH RD # 105
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73003-5006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-697-7062
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 820 W DANFORTH RD # 105
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73003-5006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE ADMINISTRATOR
-----------------------------------------------------
Name | JOHNNIE L HOWELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-697-7062
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------